One of the constraints in hospital waste management in Pakistan is ineffective legislation and the improper training about the collection, transportation and disposal of waste. In addition, unavailability of appropriate equipment for disposal (incinerators, autoclaves etc.) and insufficient budget to meet the expenses of waste management has led to many hospitals burning their waste in open environments. Lack of professional waste management teams, both at upper and lower levels, is another cause of hospital waste management failures in Pakistan. Unfortunately, scarce data is available on this issue therefore, this study has provided some of the baisc facts needed to improve hospital waste management.

Background

Open dumping of hospital waste is one of the biggest threats to the urban environments in Pakistan. Unprecedented risks are posed to public health when infectious hospital waste is openly burnt along with municipal waste. This has undermined the sustainability of breathing air quality in Rawalpindi city where population has been complaining about this issue but no proper action has been initiated to solve the problem.

Objectives

This study aimed to evaluate the waste generation, collection, segregation, transportations and disposal from major hospitals of Rawalpindi and its effect on the urban environment. An effort was made to document the effects of hospital waste burning on urban populations in order to find out the relation between ill-health effects faced by the people directly exposed to hospital waste burning.

Methodology

Primary data was collected through comprehensive surveys which included questionnaire form, personal observations, formal and informal meetings. Secondary data was collected from hospital records. Logistic Regression analysis was performed to evaluate the first hand response obtained during surveys and the presence/absence of any ill-health effect was analyzed in the context of exposure extent.

Results

The result indicated that approximately one sweeper is used for the cleaning of six beds and average daily waste generation rate was 1.55 kg day each bed, which contains 71% non-infectious and 14% infectious waste with 91% average bed occupancy rate. Three of the studied hospitals have separates waste bins for infectious and non-infectious waste collection. But unfortunately, the segregation of waste is only at the point of generation. Two of the studied hospital had wheel trolleys for waste collections while other used manpower for waste collection. Two of the studied hospitals had no proper place for the temporary storage of waste and none of the hospital had refrigerators/cooling room for the storage of pathological waste. Out of 254 responses collected during the questionnaire survey, 85% regarded themselves as directly exposed to waste burning fumes. Among ill-health effects attributed to hospital & municipal burning exposure includes in respiratory tract infections (Odds ratio = 3.18; 95% confidence interval 1.17 – 7.89) and eye irritations (Odds ratio = 2.66; 95% confidence interval 1.37 – 8.11).

Conclusion

Open burning of hospital and municipal waste must be immediately stopped as it appears to be an urban health issue. A well-managed waste administration team is required for all hospitals in Rawalpindi city to develop a multidirectional co-operation from all stakeholders, including federal and provincial governments, public, private hospitals and waste disposal staff.

Tobacco use is one of the leading causes of early deaths and is gradually increasing in developing countries like Bangladesh. Bangladesh is on the verge of tobacco epidemic as 16% of total deaths among the people aged 30 years and above is connected to tobacco use. There are many difficulties in mitigating the tobacco menace in Bangladesh despite government laws and regulations. Community level effective communication strategy/techniques were largely absent in providing meaningful information about the harmful effect of tobacco use. icddr,b has develop and tested a package of communication techniques to reduce tobacco use at the community level.

Background

Tobacco use has long been a leading contributor to premature death, and causes about 9% of deaths worldwide. Rates of smoking are increasing in many low-income and middle-income countries including Bangladesh. The proportion of tobacco-attributable deaths from tobacco use increases as the number of deaths increases. According to WHO, nearly 6 million people die from tobacco-related causes every year. If present patterns of use persist, tobacco use could cause as many as 1 billion premature deaths globally during the 21st century. Tobacco use, in particular smoking cigarettes and bidis, are common habits among the general male population in Bangladesh. Smoking related diseases such as pulmonary diseases, stroke, ischemic heart disease etc. are well documented. Smokers have a greater risk of dying from pulmonary tuberculosis as compared to non-smokers. Tobacco related illnesses accounted for 16% of the total deaths among the population of Bangladesh who are aged 30 years and above, which is about 25% of deaths in men and 7.6% in women. Smoking is also positively linked with the illicit drug use in Bangladesh. The cost of tobacco consumption at the national level is found to be associated with the increased health-care costs and loss of productivity due to illnesses and early deaths.

Objectives

The objectives of the project are to document the effectiveness of various communication techniques in reducing the tobacco use in a targeted population and design a future intervention based on the effective techniques.

Methodology

The project carried out in Chakaria, a rural sub district of Cox’s Bazar in Bangladesh where icddr,b is active in research and development activities since 1994. Fifteen villages from three unions were selected for the intervention and the same number were chosen for comparison. We have adopted various interventions in the form of Othan Baithaks or household courtyard meetings, peer group meetings, transmitting cell phone messages, counselling tobacco users through mobile phones and motivating village doctors to disseminate messages to the patients. The target audience is women and men aged 15 years and above. During the intervention, a female/male health worker showed/discussed the potential harmful effects of smoking and the dangers of passive smoking, emphasizing the idea that smokers not only put themselves at risk of serious health problems but also the people around them who are mainly family members. The health worker also transmitted the messages to all mothers that a developing baby can be affected by tobacco smoke if the mother smokes or if she is exposed to tobacco smoke during pregnancy. A video showing the harmful effects of tobacco use and large pictorial messages were displayed to communicating the message to smokers and non-smokers. Data were collected from follow-up, and mobile counselling, video sessions and process documentations were used for analyzing and interpreting the results.

Results

During January 2011-June 2103 intervention period total 9760 women/men aged 15 years and above from 1600 households participated in the Othan Baithaks and organized video sessions. 1482 households had mobile phones and 78% of these households were contacted for counselling through mobile phone. Among the population, men were most likely to use tobacco than women. Among the targeted population 1173 (12%) quit tobacco, 728 (7.5%) committed to quit and 1482 (15%) persons reduced the use of tobacco compared to their daily uptake.

Conclusion

Community level intervention can be an effective mechanism to reduce tobacco use along with government regulatory measures to combat tobacco menace. The regulatory framework can be designed such a way that the community can be engaged, informed and create a platform to use this as a prevention strategy.

Bangladesh is one of the 57 countries with a serious shortage of trained doctors, paramedics, nurses and midwives. Village doctors, a group of informally trained practitioners in modern drugs, are the dominant health care providers in the rural area. Village doctors, trained by the Centre for Equity and Health Systems (icddd,b) who had achieved an acceptable level of performance in dispensing drugs and in other desired areas related to the practice, were branded as ShasthyaSena (health soldier). The ShasthyaSenas took part in an intervention that combined their competence with that of qualified physicians through an mHealth call centre with the objective of bringing better health services to the rural community they served in.

Background

Bangladesh is one of the developing countries where 80% of the population lives in rural areas. The village doctors were most prominent contact person for consultation for any illness by the rural poor in Bangladesh. 53% of the rural population resorted to village doctors for their health services. But the village doctors are not recognized by the public sector as authentic health service providers. icddr,b has tried to train the village doctors in order to reduce harmful treatment practices since 2006 in Chakaria. There is a dearth of study regarding the engagement of village doctors or informal healthcare providers in tele-consultation (mHealth) of patients with formal provider. icddr,b operates a project to engage village doctors with the consultations of graduate doctors through mobile phones and with technical guidance from Telemedicine Reference Centre Limited (TRCL) a private entrepreneur in Bangladesh.

Objectives

The objectives of the project were to design a) an appropriate disease management scheme available to the village doctors for on the spot consultation with qualified medical personnel through a mobile phone. The range of management includes prescription by the formal physicians through SMS, prescription drugs supplied by the village doctors and referral to appropriate facilities if needed.
b) A business model aka financial incentive that can compensate village doctors and limit excess profit gained from unnecessary prescriptions.

Methodology

The study was carried out in Chakaria, a rural south east sub-district of Bangladesh. Village doctors were trained on do and don’ts for providing treatment to patients and a membership-based-network involving trained and eligible Village Doctors branded as “ShasthyaSena” (Health Frontiers) was established which give the Village Doctors logos and badges. In 2011 ShaysthaSena’s were trained on the use of mobile phone (mHealth) for consulting with graduate doctors for their patients within a revenue sharing process. A Call Centre was established, eClinic24, to link the informal providers with the formal by (TRCL). TRCL provided technical and expert support for the project. We kept all the details of implementation i.e. inception, modification, challenges, perceptions etc. and periodic process documentation.

Results

During 2011-12 program implementation periods, 110 ShasthyaSenas participated in the training and 55 registered with the eClinic24 system. Of those who registered, the utilization of the services was somewhat low. A total of 415 calls were enacted and only 26 ShasthyaSenas made those calls. 50 calls ended up in receiving prescriptions. Although there was a lot of enthusiasm among the ShasthyaSenas and the community about the mHealth, as the numbers of utilization indicates, the uptake was far below than what was expected. The major reasons for the low uptake of mHealth services mentioned by the ShasthyaSenas revolved around the problem of accessing the call centre, such as doctors not picking up the calls, long waiting period, and problems with the phones the ShasthyaSenas owned.

Conclusion

Despite low uptake at initial program implementation, mHealth can be an effective means of health services in future and ShastyaSenas can be a viable options to engage as the community have confident on them. More research in this field needed by resolving the technical problems encountered during initial phase.